More men with prostate cancer opting for active surveillance
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Key takeaways:
- From 2010 to 2018, rates of active surveillance/watchful waiting in the U.S. increased from 16.4% to 59.9% for low-risk prostate cancer.
- Asian/Pacific Islander and Hispanic men appeared less likely to undergo active surveillance.
Use of active surveillance for low-risk and favorable intermediate-risk prostate cancer increased sharply in the United States during the past decade, according to data published in JAMA Internal Medicine.
Nearly 60% of men in the U.S. with low-risk disease chose active surveillance in 2018, up from 16.4% in 2010. However, the rate still lags those of Sweden (74% by 2014) and Australia (67% by 2016), researchers wrote.
“Our findings suggest that patients and physicians are increasingly becoming more comfortable with observing a subset of cancers with low-risk features, extending the benefits of surveillance to more men,” Bashir Al Hussein Al Awamlh, MD, a urologic fellow at Vanderbilt University Medical Center, said in a press release. “However, there remains room for improvement in active surveillance uptake to reach similar rates as in some countries in Europe and Australia — particularly in light of recent data demonstrating the safety of active surveillance in low-risk cancers.”
Background and methodology
Active surveillance — the process of monitoring prostate cancer with the intention of providing curative treatment if disease progression occurs — has become increasingly recognized as the current standard of care for men with low-risk and in some cases favorable intermediate-risk prostate cancer.
In the cross-sectional study, researchers analyzed deidentified data obtained through the SEER Prostate with Watchful Waiting database of men aged over 40 years with either low-risk (n = 74,103) or favorable intermediate-risk (n = 31,699) prostate adenocarcinoma from 2010 to 2018.
Researchers excluded men with unknown treatment or missing clinical information.
Researchers used the Cochran-Armitage test and linear regression to assess for temporal trends and changes while conducting multivariable logistic regression analysis to assess associations with active surveillance/watchful waiting, rather than definitive treatment with radical prostatectomy or radiotherapy.
Results and next steps
The rate of active surveillance/watchful waiting increased from 16.4% to 59.9% for men with low-risk prostate cancer and from 7.8% to 21.8% for men with favorable intermediate-risk cancer (P < .001), according to researchers.
The median age of men who underwent active surveillance/watchful waiting decreased during the period for those with low-risk disease, from 65 years (interquartile range [IQR], 60-71) to 64 years (IQR, 59-69) and for those with intermediate-risk disease, from 70 years (IQR, 64-76) to 67 years (IQR, 61-71).
The investigators identified an association of higher income with choosing active surveillance, whereas the number of positive biopsy cores appeared to be associated with increased odds of undergoing definitive treatment (adjusted OR = 0.56; 95% CI, 0.53-0.58 for two positive biopsy cores in low-risk disease).
Asian/Pacific Islander and Hispanic men appeared less likely to undergo active surveillance than their white counterparts, while rurality appeared associated with definitive treatment for low-risk disease.
“Unfortunately, income and race and ethnicity continue to play significant roles in [prostate cancer] treatment delivery,” Al Hussein Al Awamlh and colleagues wrote. “Use of [active surveillance] continues to increase, although uptake has been lower in men with multiple positive biopsy cores and those from minority groups, with low incomes, or who live in rural areas.”
References:
- Al Hussein Al Awamlh B, et al. JAMA Intern Med. 2023;doi:10.1001/jamainternmed.2022.7100.
- More U.S. prostate cancer patients choosing active surveillance (press release). Available at: Published April 3, 2023. Accessed April 3, 2023.
Perspective
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Marc Smaldone, MD, MSHP
Active surveillance has emerged as a preferred treatment strategy that has been incorporated into existing best practice guidelines for low and favorable intermediate risk prostate cancer. While experts suggest that active surveillance may be the ideal strategy to match tumor biology to intensity of treatment it is unclear how often [active surveillance] is utilized in current practice.
This study, using SEER data from 2010-2018, reports that more than half (60%) of the patients diagnosed with low-risk prostate cancer were treated with active surveillance as opposed to more invasive treatments including surgery and radiation.
While adoption in the Unites States lags behind our European contemporaries, these data highlight the paradigm shift away from over aggressive treatment that has occurred in the management of low-risk prostate cancer over the past 10-20 years.
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